Darren D. Moore, PhD, LMFT (Georgia) is an Associate Professor & Site Director for the Couple and Family Therapy Program in San Francisco, California, at the California School of Professional Psychology at Alliant International University. Jacob Mok, BS, is a medical degree candidate at the Mercer University School of Medicine. Taylor Chandler, BS, is a marriage and family therapy master’s candidates at Mercer University. Pooja Mamidana, MS, is a recent marriage and family therapy masters graduate from Alliant International University.

Funding: No funding was provided.

Disclosures: The authors declare that they have no conflict of interest.

Abstract: The aims of this study were to 1) explore the level of training and exposure to working with bariatric patients among recent graduates of a master’s program in marriage and family therapy, and 2) gain insight regarding how recent graduates conceptualize working with bariatric patients and providing perioperative care. The authors utilized a qualitative research methodological approach (phenomenological inquiry). The research occurred in the southern United States. Participants were recent graduates of an accredited master’s programs in marriage and family therapy, specifically graduating within the last five years. The authors conducted semi-structured interviews, which were coded and analyzed by the research team. The following themes emerged in the study: 1) knowledge of bariatric surgery, 2) theoretical frameworks, and 3) perceptions of clinical treatment. The authors recommend that the topic of obesity and weight loss surgery be considered a topic of discussion within marriage and family therapy graduate and post-graduate programs. Further, marriage and family therapy students who want to specialize in bariatric counseling should gain direct exposure during graduate school by working in a collaborative healthcare setting.

Introduction

Obesity has become an epidemic in the United States. While traditional methods have been used to address the obesity epidemic, such as dietary advice, exercise, lifestyle changes, and medication, bariatric surgery has been viewed as the most effective treatment, specifically for morbid obesity.1 Although there has been an increasing number of researchers that have explored bariatric surgery, it is a life-changing procedure that has strict regulations. Initially, patients must qualify for all criteria recommended by the American Society for Metabolic and Bariatric Surgery (ASMBS) to be considered for surgery.2 After surgery, patients must adhere to lifelong commitments to maintain weight loss. Unfortunately, patients face more difficulty post-surgery, because they are required to make dramatic lifestyle changes for long-term weight loss success.3 Fostering resiliency in post-surgery patients might be the key to the acceptance of changes in their lives.4 As the number of bariatric surgeries continues to grow, more medical and mental health professionals are acknowledging the importance of pre- and post-surgery support for patients’ optimal weight loss. However, within the literature, there has been a lack of discussion regarding how marriage and family therapists (MFTs) broach working with bariatric patients, and specifically how they are trained in this regard. The purpose of this study was to explore how MFTs broach working with bariatric patients through the weight loss surgery process based on their experiences as well as their perspectives.

Methodology

The research mission was to explore how MFTs envision working with bariatric patients during the weight loss surgery process and to explore their experiences while in graduate school. For this study, the weight loss surgery process was defined as perioperative clinical intervention. The overarching research question derived was, “How do MFTs conceptualize working with bariatric surgery patients?” Additional research questions included the following: “What theoretical frameworks do MFTs utilize when thinking about clinical work with bariatric patients?” and “How do MFTs view their role in clinical treatment?” The authors employed phenomenology to gain insight into how MFTs understand and conceptualize working with bariatric surgery patients. Phenomenology is a qualitative research methodology that is used to explore the thick description and close analysis of lived experiences as created through meaning.5 Likewise, in phenomenology, reality is understood through examination of lived experiences as individuals transition through space and time.6

Research design. The researchers aimed to organize 45- to 60-minute semi-structured individual phone interviews, with the goal of obtaining depth and unique perception of each individual interviewee. Individual interviews allow for the participant to answer questions from their own perspective without possible influence of others, which might occur in focus group interviews.7 Individual interviews allowed for a streamlined approach that is congruent with the use of phenomenology as a research method, as phenomenology studies conscious experience as perceived from the subjective or first person point of view of the patient.8 Interviews were conducted until saturation was reached.9 Please see Appendix A for a list of sample interview questions.

Recruitment and data collection. After Institutional Review Board (IRB) approval, the authors engaged in a variety of recruitment strategies, including traditional and online recruitment. Traditional recruitment included a member of the research team sending an e-mail to program directors, identified faculty members, and/or administrative staff of an accredited master’s program to inform them of the study and to ask them to forward to any recent graduates. The authors also reached out to their personal network of individuals that met the criteria of being recent graduates to inquire about possible participation via snowball sampling.10 Further, the use of an online mechanism (Facebook, a social media platform) was incorporated in an effort to secure potential candidates.11,12 Once an individual expressed an interest in participating in the study, they were scheduled for an interview.

Before starting the interview, each respondent signed the informed consent document. After collecting the informed consent, participants identified a pseudonym, which was used to protect confidentiality. Directly after, an audio device was turned on and the interview was initiated. Interviews were audio recorded for transcribing purposes. Each interview was transcribed and stored securely either on the Dr. Darren Moore’s personal computer or on a device provided to an outside consultant.

Analysis. After conducting the study, Dr. Moore met with the research team to identify initial impressions and key points from the interviews. Data were analyzed by Dr. Moore and members of the research team independently and then were discussed to gain consensus regarding emerging themes. Data were analyzed by utilizing the five key stages of the “frame work analytical process,” which included the following:

Familiarization—authors became familiarized with the transcripts of data collected and gained an overview of the collected data.

Indexing—authors identified portions or sections of data that corresponded to a particular theme.

Charting—authors arranged the specific pieces of data that were indexed in the previous stage into charts of themes.

Mapping and interpretation—authors made sense of the relationship between key characteristics in the charts to finalize the emergent themes.13

Emerging themes are discussed in the results section along with representative quotes from the interviews to further illustrate each theme.

The authors incorporated credibility in the research by triangulating the data. Data were coded my multiple members of the research team in efforts to provide a robust analysis of the data and to accurately assess for emerging themes. Credibility was also incorporated through member checking purposes.14 After interviews, authors had the opportunity to ask questions for clarification if any areas of the transcript required further understanding. Respondents were also able to receive a copy of the aggregate data after the analysis and a copy of article after publication. Credibility was also incorporated through reflexivity,15 prior to approaching the study and throughout the study, the authors reflected on their positionality and epistemology regarding working with bariatric patients. The authors also considered transferability when approaching the study.16 The researchers made use of the existing literature when developing the research questions to ensure that the study contributed to gaps in the research. Likewise, the authors made attempts to consider ways to transfer the results to larger populations through developing recommendations that might inform treatment of bariatric surgery patients and MFT education and collaboration.

Demographics

There were a total of 15 individuals who participated in the study. While participants resided in various locations, all reported attending graduate school in the southern part of the United States. There were a total of five males and 10 females. The average age of participants was 32, with the range between 25 and 40 years of age. When asked about race/ethnicity, 11 individuals self-identified as “African American,” one identified as “Caucasian,” one identified as “Asian-Indian,” one identified as “Vietnamese,” and one identified as “Other.” In the study, 10 individuals self-identified as being “single,” one identified as “dating,” two identified as being “in a committed relationship,” and two identified as being “married.” When asked about weight loss surgery, 14 individuals reported that they knew someone personally who had weight loss surgery (friend, relative, or someone in their social network), with one participant who reported that they were not aware of anyone who underwent weight loss surgery. The procedures that individuals reported included gastric bypass and laparoscopic banding. When asked if participants would ever consider weight loss surgery if they needed it themselves, nine individuals reported that they would not consider surgery, with six reporting that they would consider weight loss surgery. Participants in the study graduated with their master’s degree from 2012 to 2016. For demographics, please see Appendix B, Demographics Table.

Emerging Themes

Theme 1: Knowledge of bariatric surgery. The following excerpt from an interview illustrated the first theme that emerged during the study, knowledge of bariatric surgery.

“Is bariatric surgery the same as the gastric bypass? I know there is one that is a band that automatically contracts when a person eats. It [bariatric surgery] was not focused on very heavily in our graduate program.” –Brian

MFTs were asked questions regarding their familiarity with bariatric surgery and their general knowledge of bariatric surgery. While being interviewed, four therapists reported that they were familiar with bariatric surgery, with the remaining 11 therapists reporting that they heard of bariatric surgery but were not very familiar with the medical specialty. As reflected in the representative quote above, some therapists were not familiar with the term “bariatric surgery,” but were familiar with the term “weight loss surgery.” Likewise, some participants were more familiar with specific types of surgery and discussed specific procedures when asked if they were familiar with bariatric surgery.

During the interviews, participants were asked about what specific bariatric surgical procedures they were aware of and specifically were asked to list each procedure that they could recall. When asked about surgical procedures, 11 out of 15 therapists were able to name at least one surgical procedure, with laparascopic banding (N=9) and the Roux-en-Y gastric bypass (RYGB) (N=6) being the two most reported procedures. In the study, three participants reported being familiar with the “vertical sleeve gastrectomy” procedure. While being interviewed, two participants reported that they were not able to name any bariatric surgery procedures. Further, three participants discussed cosmetic surgical procedures. For example, when asked to list bariatric surgical procedures, Grace stated, “tummy tuck,” and Destiny and Nicole replied “liposuction.”

During the interview process, participants were asked if they learned about weight loss surgery within the context of individual, couple, and family relationships during their graduate training program. Researchers found that one participant (Brian) reported that he learned about weight loss surgery as a process that clients might transition through, with the remaining 14 therapists reporting that they did not discuss weight loss surgery within the context of relational systems during their graduate training. Participants were also asked if they had any training or exposure to assessments for screening patients with obesity prior to weight loss surgery. During the study, four of the participants reported that they either had exposure to assessments or were specifically trained in assessments regarding screening patients for bariatric surgery, with 11 participants reporting not having any exposure or experience. During the interview process, the four individuals who reported having exposure to or experience with clinical assessments communicated that their experience either came from having a clinical internship in a medical setting or came after obtaining employment post-graduation.

Theme 2: Theoretical frameworks. The following excerpt from an interview illustrated the second theme that emerged during the study, theoretical frameworks.

“The post-modern approach challenges the larger narratives that are out there that are often internalized by people, whether it be a physical illness or obesity.” -Ryan

The research team determined “theoretical frameworks” to be the second theme that emerged from the study. During the interviews, 14 of the 15 participants mentioned a post-modern theory that they have used or would imagine using with a bariatric surgery patient. Out of those 14 participants, nine specifically mentioned narrative therapy. The narrative therapy approach focuses on empowering the client to re-author his or her life story. Nicole specifically said that narrative therapy could be used to “encourage hope” but most other clients listed it because it was their theory of choice. Eight of those 14 participants mentioned solution-focused therapy [some of those same participants (n=4) also listed narrative therapy]. Vela listed narrative and solution-focused theories because those are two main theories used at her hospital. She explained that a lot of the time (therapy) has to be brief because they do not see the clients on a regular basis. They only see the patients while they are at the hospital when they have had complications with their surgeries. In this case, the preference for the post-modern theories was for convenience and utility because the patients are only at the location for a limited time period.

Destiny and Brian specifically mentioned the “miracle question” as an intervention of the solution-focused method. Both participants sought to bring the future into the forefront of the conversation, and thus highlight potential strategies that the patient can use to get there. Ryan gave the most descriptive answer about why he would choose the solution-focused approach, stating:

“I think solution-focused would work well with a client with obesity because it looks at a client’s own strengths, empowering the client, and looking for exceptions—times when they are being successful. This also involves looking at a client’s self-agency and their own capabilities.” -Ryan

Cognitive behavioral therapy (CBT) was mentioned by five participants, and although there were fewer individuals that listed the post-modern approaches, they were the most specific about interventions. John and Grace said that they would focus on changing negative thoughts, Cindy would focus on cognitive restructuring and reframing, and Varnes and Wadell would journal to help notice and change thoughts.

Theme 3: Perceptions of clinical treatment. The following excerpt from an interview illustrated the third theme that emerged during the study: perceptions of clinical treatment.

“I think obesity is tied to something mental. I feel that it is a secondary symptom of something else. I think that before the weight loss there may be fear of having the surgery. Afterwards, I feel that there will be physical things that they will have to deal with, and then they will have to deal with the secondary feelings that come up. Some people think that they just feel bad because of the weight, but then they lose the weight and still feel bad about themselves.” -Lionel

The research team determined “perceptions of clinical treatment” as the third theme that emerged in the study. During interviews, participants made it clear that they (n=10) deemed support and psychoeducation to the client and their family as extremely imperative pre- and post-surgery. Participants mentioned the importance of teaching family and couple skills to patients or “clients” to help them communicate effectively so that they can be emotionally supportive to one another. Participants also stated that it was important that the entire family system attempt to create healthy eating habits pre- and post-surgery. Two participants verbalized that it is essential that patients and family members engage in support groups. Further, three participants mentioned a plethora of mental health issues that they viewed as related to bariatric surgery patients, such as eating disorders, depression, body dysmorphia, and anxiety. Three participants also mentioned that financial stress related to how the surgery is paid for and perhaps the required time off from work might impact patients.

Clinicians working from a holistic and multidisciplinary approach with medical professionals and nutritionists were seen as important by all participants. Participants felt it was necessary for medical and other health professionals to be empathetic and understand the mental health aspects of bariatric surgery, before, during, and after the procedure. Participants also communicated that it is important for mental health professionals to be involved in screening for secondary or comorbid diagnoses. For example, during the interview process, Destiny stated the following:

“My bias is that medical professionals see only the medical aspect of it and not see the mental health aspect to it. So, I would want to shed light for medical professionals on the mental health aspect.”

In addition, another participant conveyed a similar message and discussed the importance of medical professionals understanding clinical dimensions of bariatric surgery. When interviewed, Waddell stated the following:

“It is important to remind medical professionals that 93 percent of the way we communicate is nonverbal and the other seven percent is what we let come out of our mouths. I think it is very important to remind medical professionals that we need to be empathetic.” -Waddell

During the interviews, another key area of focus that participants cited was the lack of education the client has about the bariatric surgery process, including before and after surgery. Many of the clients are unaware of the healthy changes they need to make in their lifestyle and eating patterns. Participant Leila addressed a multi-generational phenomenon that might exist. She stated:

“A lot of times, I have noticed in couples and families a multigenerational pattern. There is not a lot out there on healthy habits and healthy eating, and families may have an unhealthy relationship with food in their household, putting them at a high risk for repeating the patterns as they get older. So, with regard to families, that’s a dynamic that needs to be addressed.” –Leila

The overall obstacle participants of the study feel their clients might face post-surgery sometimes is the “miracle syndrome,” where they expect that change will happen overnight or rapidly. They can be really upset when it is not the physical change or psychical weight loss that they expected. Other times, participants have seen clients shocked after being left with excess hanging skin after surgery, which might impact self-confidence and one’s desire for intimacy with their partner. Participants have also mentioned that some clients might not be prepared for the amount of food restriction required after surgery, which might contribute to physical complications and mental health problems associated with the adjustment process.

Discussion

The findings are consistent with previous work that has been conducted, which has suggested a need for training of MFTs regarding obesity and weight-related behaviors.17 The authors’ findings underscore the need to consider ways that MFTs are trained, specifically regarding working with a select group of individuals with obesity (e.g., bariatric surgery patients). Our findings suggest that while MFTs might have some ideas about the types of issues they might face when working with bariatric surgery patients, they admit that, for the most part, they have not been formally trained. While it is important that MFTs have some ideas about intervention and theoretical frameworks, some of which is conveyed in scholarly literature,17 MFTs reported that there was not a discussion about obesity in general and bariatric surgery specifically, within their graduate education.

Similar to findings among medical and nursing trainees,18 MFTs reported feeling ill prepared to work with patients with obesity and those who have undergone bariatric surgery. MFTs were not familiar with various bariatric surgery procedures and were not familiar with such nuances regarding procedures that focus on malabsorption when compared to procedures that focus on restriction or combine both malabsorption and restriction. Likewise, MFTs were not aware of some of the postoperative complications that might impact client’s experience and mental health, such as the dumping syndrome and band slippage, among others issues that might be related to the specific type of weight loss surgical intervention utilized. Given the rise of obesity and the increasing popularity of bariatric surgery among adults and some teens, it might be important that more MFTs are trained in working with patients with obesity who seek surgical intervention for weight loss. Likewise, it might be worthwhile to consider how the weight loss process impacts couple and family relationships over time as suggested by other researchers.19 One recommendation is that the topic of obesity (including weight loss surgery) is introduced within the core curriculum of MFT training. Additionally, the authors would recommend the development of formal and informal post-graduate training opportunities for MFTs to gain knowledge and experience in working with populations with obesity to include surgical and nonsurgical intervention.

Limitations and Future Research

One limitation of the study was that it was a small qualitative study and therefore cannot be generalized to a larger population. However, the authors do believe the sample yielded data that can be used to inform MFT education and can be used as a foundation for future research. In the study, there was a lack of variation in terms of geographical location of participants, with the majority of the participants having obtained their graduate degree in the southern part of the United States. Potentially, including graduates from training programs located in other parts of the United States, might have altered the results of the study. However, all the limitations support the need for future research regarding obesity and bariatric surgery training among MFTs.

Given that research at the intersection of psychosocial factors, bariatrics, and MFT is novel, there is a need for additional research to explore MFT training in graduate programs. In particular, the researchers suggest a larger quantitative study that assesses obesity and bariatric surgery knowledge among MFTs. Likewise, researchers believe it is important to consider the development of a training intervention that can be used to improve obesity and bariatric surgery knowledge of MFTs.

History of Bariatric Surgery

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